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Painful tumors of the skin – from
ENGLAND to LEND AN EGG to BLEND
TAN EGG
M. Ramesh Bhat, Anusha Ann George, Jyothi Jayaraman
Acronyms
The acronyms for painful tumors of the skin always evoke
an interest among students and teachers of dermatology. In
fact, the main author of this article was asked during his Post
Graduate examination about the acronym ENGLAND. Over
the years with the addition of newer entities, new acronyms
have been developed. The only common symptom attributed
to these heterogeneous benign tumors is pain. We also had the
opportunity to publish a few case reports related to atypical
presentations of these tumors.1‑3 The acronym ENGLAND
or GLENDA is often used to recall these tumors – eccrine
spiradenoma, neuroma, glomus tumor, leiomyoma,
angiolipoma, neurilemmoma and dermatofibroma. Naversen
et al. modified the acronym “LEND AN EGG” with the
addition of endometrioma and granular cell tumor.4 With
the addition of blue rubber bleb nevus and tufted angioma
to this list, presently the acronym stands as “BLEND TAN
EGG.”2 In this article, we have briefly described the clinical
features and analyzed the pathogenesis of pain in these
tumors [Table 1].
Blue Rubber Bleb Nevus
It is characterized by cutaneous and gastrointestinal venous
malformations. Skin lesions have a cyanotic bluish appearance
with soft elevated nipple‑like projections. Nocturnal pain is
characteristic.5
Department of Dermatology, Father Muller Medical College, Mangalore,
Karnataka, India
Correspondence: Dr. M. Ramesh Bhat,
Department of Dermatology, Father Muller Medical College,
Mangalore ‑ 575 002, Karnataka, India.
E‑mail: rameshderma@yahoo.com
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Leiomyoma
This tumor develops from smooth muscles.6 Solitary and
multiple piloleiomyomas are derived from arrector pili
muscle and angioleiomyomas are derived from muscles of
vein.7 These lesions present as solitary or grouped red, pink,
purple, brown, waxy or translucent nodules [Figures 1 and 2].
On histopathological examination, interlacing bundles of
smooth muscle bundles with characteristic eel‑shaped nuclei
are seen [Figure 3].4
Eccrine Spiradenoma
It presents as painful, blue‑colored, small, nondescript lesions
showing histologic differentiatiion towards intradermal
eccrine ductal and secretory cells. Histopathology shows
deeply basophilic stained, sharply marginated lobules
lying freely in the dermis. Two types of epithelial cells are
present – small cells with dark peripheral nuclei and pale
cells with central nuclei.8‑10 Characteristic appearance is
called “blue balls” in the dermis.11
Neuromas
These tumors present as painful skin colored lesions which
are characterized by proliferative bundles of nerve fibres with
a surrounding capsule on histopathology. Morton’s neuroma
presents as a reactive, persistent and degenerative nodule
commonly over the sole.4
Dermatofibroma
It presents as a painful hyperpigmented nodule with “dimple
sign” most commonly over the legs4 [Figure 4]. Histopathology
shows a hyperplastic epidermis separated by a grenz zone
from a dermal tumor composed of varying proportion of
histiocytes and blood vessels [Figure 5].12
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How to cite this article: Bhat MR, George AA, Jayaraman J. Painful
tumors of the skin – from ENGLAND to LEND AN EGG to BLEND
TAN EGG. Indian J Dermatol Venereol Leprol 2019;85:231-4.
Received: February, 2017. Accepted: December, 2017.
231
Bhat, et al.
Figure 1: Leiomyoma cutis: multiple, hyperpigmented, soft nodules over left
shoulder, arm and upper back
Figure 3: Histopathology of leiomyoma: Dermis shows intersecting
fascicles of smooth muscle bundles intermingled with collagen bundles in
histopathology on high power (hematoxylin and eosin, ×400)
Tufted Angiomas
Tufted angioma is an uncommon, benign, vascular tumor that
usually develops during infancy or childhood, with a majority
of lesions arising before the age of 5 years.13 It typically
presents on the neck, shoulders, trunk or groin as slowly
expanding, mottled, red‑to‑purple patches and firm plaques
superimposed with papules and nodules. Lesions are often
associated with paroxysmal pain or tenderness to palpation and
localized hyperhidrosis as well as hypertrichosis have been
observed.14 Kasabach–Merrit syndrome has been associated
with congenital tufted angioma. Histopathologically, tufted
angiomas are characterized by multiple, discrete lobules of
tightly packed capillaries in a cannonball pattern within the
dermis and sometimes in subcutis.15
232 Indian Journal of Dermatology, Venereology and Leprology | Volume 85 | Issue 2 | March-April 2019
Painful tumors of skin
Figure 2: Leiomyoma cutis: multiple skin‑colored to hyperpigmented nodules
with a few appearing translucent
Table 1: Causes of pain in “BLEND TAN EGG”23‑27
Tumor Pathogenesis of pain
Blue rubber bleb Pain caused by contraction of smooth muscle fibers
nevus surrounding the nevus23
Leiomyoma cutis Due to presence of involuntary smooth muscle fibers
Eccrine Disorganized nerve fibres encasing the spiradenoma
spiradenoma nodules seems to contribute to intense pain24
Neuroma Presence of nerve tissue
Dermatofibroma Probable cause could be entrapped collagen bundles in
between interlacing strands of fibroblasts or histiocytes25
Tufted angioma Growth factors (e.g., interleukin‑8) and inflammation
may be responsible for pain26
Angiolipoma Thrombosis of the capillaries close to the capsule of
the tumor27
Neurilemmoma Presence of Schwann cells
Endometrioma Hormonal stimulation of endometrial tissue
Granular cell tumor Schwann cell origin and possible neural differentiation
Glomus tumor Presence of modified smooth muscle cells
Angiolipoma
It is a variant of lipoma.4 Cutaneous angiomyolipomas are rare
and differ from renal angiomyolipomas in that they are more
common in males 33–77 years of age without any association
with tuberous sclerosis and are HMB‑45 negative. Histologically,
they are composed of thick‑walled blood vessels, smooth muscle
cells and mature fat in variable proportions. Epithelioid cell
component is usually absent in cutaneous angiomyolipomas in
contrast to renal angiomyolipomas, which may be responsible
for HMB‑45 negativity.16
Neurilemmomas
These are nerve sheath tumors presenting as ovoid,
rounded, firm, circumscribed nodules.17 Neurilemmoma is
Bhat, et al.
Figure 4: Dermatofibroma: solitary, hyperpigmented firm nodule over upper back
Figure 6: Glomus tumor: dusky, cyanotic nodule over the left calf
one of the few truly encapsulated neoplasms of the human
body.18 Schwann cells are arranged in bands which stream
and interweave. Cellular areas are known as Antoni A areas
which are intermixed with areas showing predominantly
myxoid change and named as Antoni B areas.17
Endometrioma
It is a rare skin tumor presenting with pain and bleeding which
worsens at the time of menstruation. It usually appears over
a scar or near umbilicus.19 Histopathology shows a cellular
vascular stroma with lumina as well as changes associated
with various phases of menstrual cycle.20
Granular Cell Tumor
It occurs most commonly over the tongue. Histopathology
shows irregular polygonal, large cells with poorly‑defined
membrane and granular cytoplasm.17
Indian Journal of Dermatology, Venereology and Leprology | Volume 85 | Issue 2 | March-April 2019
Painful tumors of skin
Figure 5: Histopathology of dermatofibroma: Storiform pattern of
spindle‑shaped cells on high power (hematoxylin and eosin, ×400)
Figure 7: Histopathology of glomus tumor: with hematoxylin and eosin stain
showing a well‑defined tumor in the dermis with solid sheets of tumor cells
which are surrounding vascular channels (×100)
Glomus Tumor
This is a neoplasm of normal glomus body with a triad of
symptoms of pain, pinpoint tenderness on blunt palpation
and hypersensitivity to cold.21 Commonly seen over digits
but extradigital locations have also been described. We
have reported a case of glomus tumor over the calf region
[Figure 6].22 Histopathology shows branching vascular
channels separated by connective tissue stroma containing
aggregates, nests and masses of glomus cells [Figure 7].3
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given his
233
Bhat, et al.
consent for his images and other clinical information to be
reported in the journal. The patient understand that name and
initials will not be published and due efforts will be made to
conceal identity, but anonymity cannot be guaranteed.
Acknowledgment
The authors would like to acknowledge Dr. Sherina Laskar,
MD, DNB, Department of Dermatology, Gauhati Medical
College for her contribution towards reference articles for
causes of painful tumors of the skin.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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